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Hyperkeratotic palmar dermatitis

Authors: Dr Sarajane Ting, General Practitioner, Wellington, New Zealand; A/Prof Rosemary Nixon, Dermatologist, Melbourne, VIC, Australia. DermNet Editor in Chief: Adjunct A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Copy edited by Gus Mitchell. February 2020.


What is hyperkeratotic palmar dermatitis?

Hyperkeratotic palmar dermatitis is a form of eczema in which there is thick scaling on the palms. Hyperkeratotic palmar dermatitis occurs without any obvious co-existing skin disease [1,2].

Hyperkeratotic palmar dermatitis is also known as hyperkeratotic hand eczema, hyperkeratotic eczema of the palms, and psoriasiform hand/palmar eczema.

Hyperkeratotic palmar dermatitis

Who gets hyperkeratotic palmar dermatitis?

Hyperkeratotic palmar dermatitis occurs more commonly in men than in women [2,3]. The age of onset tends to be later than in other subtypes of hand eczema, most often occurring at middle age.

What causes hyperkeratotic palmar dermatitis?

The cause of hyperkeratotic palmar dermatitis is unknown. It is classified as endogenous dermatitis [1–3]. Manual work is a risk factor for the development of hyperkeratotic palmar dermatitis, but patients do not generally report exposure to skin irritants or contact sensitisation [2,4,5].

Hyperkeratotic palmar dermatitis does not appear to be genetic in origin and there is no association with psoriasis or atopic dermatitis [1,5].

  • The clinical features of hyperkeratotic palmar dermatitis and palmar psoriasis are similar, but there is no increased personal or family history of psoriasis.
  • Human leukocyte antigens (HLA) associated with psoriasis are not increased in patients with hyperkeratotic palmar dermatitis.
  • The incidence of personal and family history of atopic diseases is not increased in patients with hyperkeratotic palmar dermatitis.

What are the clinical features of hyperkeratotic palmar dermatitis?

Hyperkeratotic palmar dermatitis typically presents as sharply demarcated, hyperkeratotic, and fissured lesions in the middles of both palms. It typically starts in one palm and progresses to involve the other palm and the volar surfaces of the fingers. Hyperkeratotic plantar dermatitis may occur in some cases [1–3].

Patients usually report itching. Fissures, if present, can be painful [1,3]. There are no vesicles or pustules. Nails are not affected [2,3].

Painful fissuring in hyperkeratotic palmar dermatitis

How is hyperkeratotic palmar dermatitis diagnosed?

Hyperkeratotic palmar dermatitis is diagnosed clinically. The challenge is to distinguish between potential causes of palmar hyperkeratosis. Investigations may include:

What is the differential diagnosis for hyperkeratotic palmar dermatitis?

Several skin conditions may be confused with hyperkeratotic palmar dermatitis.

Palmar psoriasis

  • Psoriasis-type scale is usually absent in hyperkeratotic palmar dermatitis [4].
  • Hyperkeratotic palmar dermatitis is usually itchier than palmar psoriasis [3,7].

Irritant contact dermatitis

  • Irritant contact dermatitis is excluded by a negative history of exposure to relevant irritants.
  • Irritant contact dermatitis is usually less localised and not well-demarcated [2].

Allergic contact dermatitis

Atopic dermatitis

  • Hyperkeratotic phases can occur in atopic hand dermatitis.
  • Unlike atopic dermatitis, hyperkeratotic palmar dermatitis is circumscribed, and has a later age onset than atopic dermatitis (which usually starts in infancy and childhood) [5].

Lichen simplex chronicus

Tinea infection

  • Tinea manuum is usually unilateral.
  • It is often associated with tinea pedis and tinea unguium.
  • Tinea results in diffuse scaling or flaking of the palm instead of circumscribed hyperkeratotic plaques [7].

Other conditions to consider include:

What is the treatment for hyperkeratotic palmar dermatitis?

Compared to other subtypes of hand eczema, topical formulations are less effective in hyperkeratotic palmar dermatitis, resulting in a greater need for systemic treatment [11]. Acitretin has been found to be effective in the treatment of hyperkeratotic palmar dermatitis and often is useful at relatively low doses [12].

General measures

  • Use appropriate protective gloves for all manual handling and for all wet work.
  • Protective gloves should be intact, clean, and dry inside, and used for as short a time as possible.
  • When protective gloves are used for more than 10 minutes, cotton gloves should be worn underneath.
  • Avoid repetitive hand washing.
  • Use a non-soap cleanser and make sure that hands are dried completely after washing.
  • Note that cream cleansers are not antimicrobial; soap and water or a sanitiser is needed for washing hands in order to destroy pathogens such as the SARS-CoV-2 virus responsible for COVID-19.

Topical treatments

Topical treatment options for hyperkeratotic palmar dermatitis include:

Physical therapy

Physical therapies for hyperkeratotic palmar dermatitis include:

Systemic therapy

Systemic therapies for hyperkeratotic palmar dermatitis include:

What is the likely outcome for hyperkeratotic palmar dermatitis?

Hyperkeratotic palmar dermatitis tends to follow a stable, chronic clinical course. Spontaneous resolution is uncommon [5]. Treatment with acitretin can result in a significant reduction in symptoms over a four-week treatment period [12,13]. This improvement has been shown to persist for five months after withdrawal of acitretin [13].

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Related information

 

 References

  1. Feldman SR, Taheri A. Hyperkeratotic Eczema of the Palms. In: Alikhan AL, Jean-Marie Maibach, Howard I, editor. Textbook of Hand Eczema. Berlin, Heidelberg: Springer; 2014. p. 139–47.
  2. Diepgen TL, Andersen KE, Chosidow O, Coenraads PJ, Elsner P, English J, et al. Guidelines for diagnosis, prevention and treatment of hand eczema. J Dtsch Dermatol Ges 2015; 13: e1–22. PubMed
  3. Menné T, Johansen JD, Sommerlund M, Veien NK, Group DCD. Hand eczema guidelines based on the Danish guidelines for the diagnosis and treatment of hand eczema. Contact Dermatitis 2011; 65: 3–12. PubMed
  4. Johansen JD, Hald M, Andersen BL, Laurberg G, Danielsen A, Avnstorp C, et al. Classification of hand eczema: clinical and aetiological types. Based on the guideline of the Danish Contact Dermatitis Group. Contact Dermatitis 2011; 65: 13–21. PubMed
  5. Hersle K, Mobacken H. Hyperkeratotic dermatitis of the palms. Br J Dermatol 1982; 107: 195–201. PubMed
  6. Park JY, Cho EB, Park EJ, Park HR, Kim KH, Kim KJ. The histopathological differentiation between palmar psoriasis and hand eczema: A retrospective review of 96 cases. J Am Acad Dermatol 2017; 77: 130–5. PubMed
  7. Chopra A, Gill SS, Maninder. Hyperkeratosis of palms and soles : clinical study. Indian J Dermatol Venereol Leprol 1997; 63: 85–8. PubMed
  8. Lachapelle J-M. Clinical Subtypes and Categorization of Hand Eczema: An Overview. In: Alikhan A, Lachapelle J-M, Maibach HI, editors. Textbook of Hand Eczema. Berlin, Heidelberg: Springer; 2014. p. 25–36.
  9. Hald M, Agner T, Blands J, Ravn H, Johansen JD. Allergens associated with severe symptoms of hand eczema and a poor prognosis. Contact Dermatitis 2009; 61: 101–8. PubMed
  10. Egawa K. Topical vitamin D3 derivatives in treating hyperkeratotic palmoplantar eczema: a report of five patients. J Dermatol 2005; 32: 381–6. PubMed
  11. van der Heiden J, Agner T, Rustemeyer T, Clemmensen KKB. Hyperkeratotic hand eczema compared to other subgroups of hand eczema - a retrospective study with a follow-up questionnaire. Contact Dermatitis 2018; 78: 216–22. PubMed
  12. Thestrup-Pedersen K, Andersen KE, Menné T, Veien NK. Treatment of hyperkeratotic dermatitis of the palms (eczema keratoticum) with oral acitretin. A single-blind placebo-controlled study. Acta Derm Venereol 2001; 81: 353–5. PubMed
  13. Capella GL, Fracchiolla C, Frigerio E, Altomare G. A controlled study of comparative efficacy of oral retinoids and topical betamethasone/salicylic acid for chronic hyperkeratotic palmoplantar dermatitis. J Dermatolog Treat 2004; 15: 88–93. PubMed

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